Article URL: /Application/members/135/136/primetimehealthplan/t/Portal.aspx Print Date:9/19/2024 Last Modified: 10/1/2013 12:00:00 AM

Eligibility and Enrollment - Basic Select

To be eligible for our HMO PLAN Options:
  • Must have Part A & B
  • Must reside in one of the following counties within Ohio
    • Stark
    • Carroll
    • Columbiana
    • Holmes
    • Harrison
    • Jefferson
    • Mahoning
    • Summit
    • Tuscarawas
    • Wayne
  • Only pre-existing ESRD not eligible to join PrimeTime Health Plan
  • Members may enroll in the plan only during specific times of the year. Contact PrimeTime Health Plan for more information

2013 Enrollment Instructions and Forms

HMO Enrollment Form

Enrollment Form Addendum

Electronic Funds Transfer (EFT) Form

Optional Supplemental Benefits Enrollment Form

Medicare Online Enrollment

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